HomeMy Public PortalAbout5019ALESSANDRO AVE_Building (4) APPLICATION FOR. BUILDING PERMIT i1
COUNTY OF LOS ANGELES . BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATIOW
FOR APPLICANT TO FILL IN BUILDING AD R SS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS �r�r LE d 0 AV.
ora certificate of Workers'Compensation Insurance,or a certified CITAilogo zip Tc1'1 LE CITy, 4r--A, q1-7 �Q
copy thereof(sec.3800,AabPolicy No� Com an /V � G ® LOCALITY
p y SIZE OF LOTNO.OF BLDGS.NOW ON LOT
❑ Certified Copy is hereby furnished. O NEAREST CROSS ST.
Certified copy is filed with the county building inspection TRACT BLOCK LO
department. (2 S f USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE• PA Q SPECIA NDITIONS
Date pplicant 1� ® �� OQ
CERTIFICA E OF EXEMPTION FROM WORKERS' OWNER j TEL.NO.
COMPENSATION INSURANCE ;qpG I WITHIN 1000
ADDRESS F SCHOOL? YES No
(This section need not be completed if the permit is for one hundred O DISTRI GROUP TYPE CONST.' FIRE ZONE CES D BY
dollars($100)or less.) CITY
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I certify that in the performance of the work for which this permit !Il/1 R:Yl� V-Al 3
I4
is issued, I shall not employ any person in any manner so as to ARCHITEC ENGI E TEL.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT ONDO
Date Applicant ADDRE CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate o CONT TOR TEL REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to. the Workers !L D SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith D a FRONT
comply with such provisions or this permit shall be deemed revoked. DR LIC.NO. PL
6
SIDE >'
LICENSED CONTRACTORS DECLARATI C LIC.CLAs PL o
I hereby affirm that I am licensed under provisions of C r 9 SEWER MAP CD
(commencing with Section 7000)of Division 3 of the Busi d N T R NO.OF F MILIES
Professions Code,and my license is in full force and a ct. I NEW ❑ BK PG
License Number Lia Class RI O '600 q
ADD VALUATION ,.,q
W
Contractor ,?ALTER ❑ $,?"' ° D y
z
❑ I am exempt under Sec.
REPAIR ❑ $
B.&P.C.for this reason f DEMOL ElLDMAP/C#
Date: US X�TING BLDG. 'L /TDI E URM. ❑
Signature APP ANT(PRINT) TEL.NO.
LDMA Perm# L
❑ I, as owner of the property, or my employees with wages a - Z s
DRESi's•t.•
their sole compensation, will do the work and the structur Is —
not intended or offered for sale (Section 7044, Busin and FINAL DATE
..0 J•JL t Jd1'iJ a' _'
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPA HAN�INF
HAZARDO 1 J i q
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQTO OR G Q 1 1 I�}i�
❑ I, as owner of the property, am exclusively c ratting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALSR TIO UI FINAL BY
licensed contractors to.construct the proj .(Section 7044, T s q z,
VES❑ NO❑ !S I t AL 348 ea a-15_F
Business and Professions Code.) � D 6
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR TU E BUILDING - { Lam,''{/• `"`' •`
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHECK .43.LiL
CONSTRUCTION LE ING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST h
FOR GUIDELINES. A
w.l•f�i :�E a i le i
I hereby affirm that there is onstruction lending agency for YES❑ NO❑
the performance of the wor or which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097,CIV.C.J. PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES_- '1131-100-1300
f ,^y } t- /
o Lenders Name COUNTVCODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING ,I-31-1 k3-13 01 5f ��'/T(
HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
Lender's Address !I K f AM 10 o C1 S
OWNER OR AGENT
o 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE, /s '
information is correct. I agree to comply with all county `I)
ordinances and State laws relating to building construction,and +
a. hereby authorize representatives of this County to enter upon ISSUANCE FEE
t bove- entioned propejo for inspection purposes. U
a .46- / INVESTIGATION FEE TOTAL FEE
sig e m of a Ag,n Gem
SEE REVERSE FOR EXPLANATORY LANGUAGE,